Case Report

iMedPub Journals 2016

Head and Neck Cancer Research
http://www.imedpub.com ISSN 2572-2107 Vol. 1 No. 2: 10

DOI: 10.21767/2572-2107.100010

Carcinoma Thyroid with Hyperthyroidism - A Vudayaraju H1, Korukonda S2

and Dara H2
Rare Case Report
1 Chief Consultant Surgical Oncologist,
Yashoda Superspeciality Hospital,
Secunderabad, Telangana, India
Abstract 2 Surgical Oncology DNB Resident,
Yashoda Superspeciality Hospital,
Thyroid malignancies are most commonly associated with either euthyroid or Secunderabad, Telangana, India
hypothyroid. It is very rare to find hyperthyroidism coexisting with a carcinoma of
thyroid. We present such rare case of a papillary carcinoma thyroid patient with
hyperthyroidism. Corresponding author: Korukonda S
Keywords: Papillary carcinoma thyroid; Hyperthyroidism; Graves disease; LATS;
TSH; Thyroid hormone receptor gene (TSH-r)
 sowmya_heidi@yahoo.co.in

Received: July 05, 2016; Accepted: July 15, 2016; Published: July 22, 2016 Surgical Oncology DNB Resident, Yashoda
Superspeciality Hospital, Secunderabad,
Telangana, India.

Introduction Tel: +919885130274

Thyroid malignancies and hyperthyroidism are rare associations.
Hyperfunctioning diseases of thyroid have always been thought
as “unsuspected lesions” because past theories have suggested
Citation: Vudayaraju H, Korukonda S, Dara
that hyperthyroidism protects from thyroid cancer owing to a lack
H. Carcinoma Thyroid with Hyperthyroidism
of stimulation to thyroid tissue itself by TSH1 (Thyroid Stimulating
- A Rare Case Report. Head Neck Cancer
Hormone). We report a rare case of a papillary carcinoma thyroid
Res. 2016, 1:1.
patient who presented with hyperthyroidism.

Case Report and old hemorrhage. FNAC from the cervical lymph node showed
A 43 year old male presented with a history of swelling in the metastatic papillary thyroid carcinoma.
right lateral aspect and in the midline of the neck since 3 months.
Patient was advised antithyroid drugs, Tab. Neomercazole 10
He complained of sweating and palpitations. He had lost weight,
mg thrice a day and Tab. Propronalol 20 mg twice a day for 10
however his appetite was normal. There was no past history of
days. The doses of the drugs were readjusted according to the
radiation to head and neck.
symptoms and the thyroid profile. His symptoms improved,
Physical examination revealed an anxious patient with a staring thyroid profile came down to normal range in 3 weeks and then
look and fine tremors of the out stretched hands. His resting he was planned for the surgery.
pulse rate was 110/min. On examination of the neck, he had 4 ×
Total thyroidectomy with central neck dissection and right postero-
3 cm firm, nodule in the right lobe of thyroid. No nodules were
lateral neck dissection was performed. During surgery the gland
palpable in the isthmus and left lobe. Multiple significant nodes
was found to be very vascular and the nodes were cystic and
were palpable in the right level III and IV, largest is about 4 × 4 cm
black in colour characteristic of a metastatic deposit of papillary
in the level III. No lymph nodes were palpable on the left side of
carcinoma. Patient also had pretracheal and paratracheal nodes.
the neck.
Histopathological examination showed a right lobe of size 6 × 4
Thyroid function tests confirmed that the patient was in
× 3 cm and left lobe of size 4 × 2 × 2 cm. Cut surface of right lobe
hyperthyroid state, TSH: <0.01 micro IU/ml, T3: 2.44 ng/ml, T4:
showed grey white nodule measuring 1.2 × 1 × 1 cm, another
16.30 mcg/dl. Ultrasound neck showed multiple hypoechoic
nodule measuring 0.3 × 0.3 × 0.2 cm. Another cyst filled with
areas of right thyroid lobe, largest measuring 2.4 × 15 mm,
colloid measuring 3.5 × 2 × 2 cm. Isthmus and left lobe is normal.
multiple small level II, III, IV right cervical lymph nodes noted.
7 lymph nodes in the central compartment and 25 lymph nodes
Ultrasound guided FNAC of the thyroid was suggestive of follicular
in the right lateral neck, with perinodal extension. Microscopy
adenoma thyroid with hemorrhage and cystic degeneration.
showed differentiated papillary carcinoma of right lobe with
Repeat FNAC from the thyroid nodule showed abundant colloid

© Under License of Creative Commons Attribution 3.0 License | This article is available in: http://head-and-neck-cancer-research.imedpub.com/archive.php
1

negative central neck nodes and 6 out of 20 positive nodes in the
right lateral neck. Tumor has both solid and cystic components
and another separate nodule is seen within the right lobe (Stage:
I disease - 43 yr old, T2- largest nodule is about 3.5 × 2 × 2 cm,
N1b - right lateral cervical nodes were positive for malignancy,
M0- No distant metastasis).
Discussion
Risk of malignancy in clinically hyperthyroid patients was
considered low until recently. The incidence in various worldwide
literature ranges from 0.8 to 0.4% [1,2]. In the past five years at
our institute there were about 200 cases of papillary carcinomas
operated and none of them had hyperthyroidism.
The association can be of two forms. An incidental focus of
carcinoma in specimens resected for hyperthyroidism or a known
patient of carcinoma thyroid presenting with hyperthyroidism
which was the case in our patient. Later, association became
rare than the former. Such patient presenting with metastatic
secondary’s is much rare. Most of the carcinomas associated with
hyperthyroidism are papillary carcinomas [3].
In our case, repeated FNAC from the thyroid nodule did not
reveal malignancy, finally the cytology from the nodal mass
showed metastatic papillary carcinoma. The basis of this
interesting association of malignancy and hyperthyroidism is
being investigated. Initially hyperthyroidism was attributed to the
increased volume of thyroid tissue even in the face of decreased
function associated with malignancy [4]. Some workers have
2 This article is available in: http://head-and-neck-cancer-research.imedpub.com/archive.php
Head and ARCHIVOS DEResearch
Neck Cancer MEDICINA 2016
ISSN
ISSN 1698-9465
2572-2107 Vol. 1 No. 2: 10
raised the role of long acting thyroid stimulator (LATS) and LATS-
protector (LATSP) in stimulation of carcinogenesis in Graves’
disease [5]. More recently, increasing reports on the possible
carcinogenic role of thyroid binding immunoglobulin (TBIg) and
other immunoglobulins in Graves’ disease are mentioned in the
literature [6].
Activating mutation of thyroid hormone receptor (TSH-r) gene has
been demonstrated in a hyper functioning differentiated cancer.
This mutation through activation of cAMP signal transduction is
believed to cause hyperthyroidism [7].
In an autonomously functioning thyroid follicular carcinoma,
a combination of mutations of TSH receptor and K-RAS was
found to be responsible for hyper function of the tumor and the
carcinogenic process [8].
Hyper functioning thyroid carcinoma should always be considered
in the differential diagnosis of thyrotoxicosis/hyperthyroidism.
This association of hyperthyroidism and malignancy has
considerable therapeutic significance. Functioning thyroid
carcinomas require total thyroidectomy with or without neck
dissection. Normalization of the thyroid hormone levels by anti-
thyroid drugs like Neomercazole is mandatory for the preoperative
preparation. Propranolol is useful for symptomatic control. Post-
operative radioactive iodine therapy is given as indicated.
This rare case report emphasizes the need for thorough evaluation
of thyroid gland to exclude malignancy even in a clinical setting
of hyperthyroidism which would mandate a total thyroidectomy
rather than the other modalities of treatment routinely employed
for a thyrotoxic goitre.
 Head and ARCHIVOS DEResearch
Neck Cancer MEDICINA 2016
ISSN
ISSN 1698-9465
2572-2107 Vol. 1 No. 2: 10

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